Dual Enrollment Application for Marchman Technical College Career Certificate Programs

Which program are you applying for?
Prior Enrollment Status:
Name: Name: First Last
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email:
Date of Birth: Date of Birth: / MM / DD YYYY
Phone: Phone: - ### - ### ####
Social Security Number:
If applicable Pasco County Student ID:
Gender:
Birthplace: City
Birthplace: State or Country
Race: American Indian or Alaska Native

Race: American Indian or Alaska Native Yes No
Race: Native Hawaiian or Other Pacific Islander

Race: Native Hawaiian or Other Pacific Islander Yes No
Race: Black or African American

Race: Black or African American Yes No
Ethnicity: Hispanic or Latino

Ethnicity: Hispanic or Latino Yes No
Race: Asian

Race: Asian Yes No Third option
Race: White

Race: White Yes No
Single Ethnicity:

Single Ethnicity: American Indian or Alaskan Native Asian Black, Non-Hispanic Hispanic Multi/Other Native Hawaiian or other Pacific Islander White, Non-Hispanic
Employment Status:
Parental Status (Student):

Parental Status (Student): Single Parent Single Pregnant Woman Both - Single Parent and Pregnant Not Applicable
Do any of the following apply to you as a Displaced Homemaker:

Do any of the following apply to you as a Displaced Homemaker: Participant is providing services to family members in the home and is the dependent spouse of a member of the Armed Forces on active duty Parent whose youngest child will become ineligible (at age 16) to receive assistance under the program for Aid to Families with Dependent Children under Part A of the Title IV of the Social Security Act Been dependent on public assistance or on the income of a relative but is no longer supported by such income Worked as an adult primarily without remuneration to care for home and family Not Applicable
Are you a United States Veteran?
Do you have any of the following medical diagnosis?

Do you have any of the following medical diagnosis? Asthma Cardiac (heart) abnormalities Diabetic High Blood Pressure Seizures Do you have an Epi - pen? No. I do not have any of these medical diagnosis
Do you have any additional health problems or allergies of which the school should be aware of?
Do you take any routine medications?

Do you take any routine medications? Yes No
If you answered yes to the above, please list any routine medications:
Medical Emergency Care Treatment Authorization

In case of accident or serious illness, I authorize the school to make whatever arrangements are necessary to provide care and treatment. I agree to pay all expenses incurred by the handling of this emergency care.

I hereby authorize Pasco County Schools to release and exchange my confidential information, related to emergencies, to Pasco County Fire Rescue and/or the nearest hospital, in order to provide medical care on my behalf, if I am unable to provide the information.

By signing below I agree with the Medical Emergency Care Treatment Authorization terms and conditions above. Medical Emergency Care Treatment Authorization

In case of accident or serious illness, I authorize the school to make whatever arrangements are necessary to provide care and treatment. I agree to pay all expenses incurred by the handling of this emergency care.

I hereby authorize Pasco County Schools to release and exchange my confidential information, related to emergencies, to Pasco County Fire Rescue and/or the nearest hospital, in order to provide medical care on my behalf, if I am unable to provide the information.

By signing below I agree with the Medical Emergency Care Treatment Authorization terms and conditions above. First Last
What is your purpose for attending Marchman Technical College (please check one):

What is your purpose for attending Marchman Technical College (please check one): Employment - I am attending school in order to obtain employment in the field of my program of study. Personal Enrichment – I am attending school to increase my skills and do not plan to seek employment in the field of my program of study.
Please read the MTC Student Code of Conduct before proceeding any further.

I understand that I must read and agree to the MTC student code of conduct and technical program catalog to finalize this application(both documents may be found at www.fkmtc.edu.)

Please read the MTC Student Code of Conduct before proceeding any further.

I understand that I must read and agree to the MTC student code of conduct and technical program catalog to finalize this application(both documents may be found at www.fkmtc.edu.) I have read and agree to the MTC student code of conduct and technical program catalog
PASCO COUNTY SCHOOLS MEDIA RELEASE FORM

Pasco County Schools (the District) strives to celebrate the accomplishments of its students by sharing information with the community. To do this, the District may submit press releases to local media (newspapers, radio, television, online news blogs) that include student names, student work,student photographs, and video and/or voice recordings.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are not permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

I understand that if I do not wish to grant permission to Pasco County Schools to release my information as defined above I must complete a Media Release Form that must be completed by me, in person, at the administration office on campus.

PASCO COUNTY SCHOOLS MEDIA RELEASE FORM

Pasco County Schools (the District) strives to celebrate the accomplishments of its students by sharing information with the community. To do this, the District may submit press releases to local media (newspapers, radio, television, online news blogs) that include student names, student work,student photographs, and video and/or voice recordings.

In addition, the District may choose to publish and/or display this information in District sponsored publications, at various school or public functions, on the District’s local cable channel, website(s) and various social media channels, or in the school yearbook. While the intent of this practice is to be informative and celebratory, the District recognizes that concerns may arise regarding a student’s right to privacy.

Pursuant to the Federal Family Educational Rights and Privacy Act (FERPA), school districts are not permitted to release "school directory information" unless applicants exercise their right of refusal. Under the FERPA law, this information could include: student name, residential address, e-mail address, phone numbers, photographs/images, school locations, field of study, degrees, honors and awards received and participation in athletics and other activities.

It is the intent and practice of the School District to publish, post, or release ONLY an applicant’s name,photograph, audio and/or video recording, displays of student work or other school-related information and ONLY as related to student achievement (e.g. academic/athletic recognition or award) or student accomplishment (e.g. a specially selected piece of work).

I understand that if I do not wish to grant permission to Pasco County Schools to release my information as defined above I must complete a Media Release Form that must be completed by me, in person, at the administration office on campus. I have read and agree to the media release terms and conditions
NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS

NOTICE TO BUILDING OCCUPANTS AND PARENTS

The Environmental Protection Agency (EPA) has issued a final rule, 40 CFR Part 763, Asbestos Containing Material in schools, commonly referred to as AHERA. This rule requires all Local Education Agencies (LEA’s) to identify asbestos containing materials (ACM) in their school buildings and to take appropriate actions to control the release of asbestos fibers.

All inspections for Marchman Technical College have been completed and a Management Plan describing the results of the inspection and the action plan to control any asbestos found during the inspection, where applicable, has been submitted to the governor for approval. A copy of this plan is located in the administrative office of this school and at the Pasco County Schools Maintenance & Facility Services Department and is available for review upon request.

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS.

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS

NOTICE TO BUILDING OCCUPANTS AND PARENTS

The Environmental Protection Agency (EPA) has issued a final rule, 40 CFR Part 763, Asbestos Containing Material in schools, commonly referred to as AHERA. This rule requires all Local Education Agencies (LEA’s) to identify asbestos containing materials (ACM) in their school buildings and to take appropriate actions to control the release of asbestos fibers.

All inspections for Marchman Technical College have been completed and a Management Plan describing the results of the inspection and the action plan to control any asbestos found during the inspection, where applicable, has been submitted to the governor for approval. A copy of this plan is located in the administrative office of this school and at the Pasco County Schools Maintenance & Facility Services Department and is available for review upon request.

NOTIFICATION OF INSPECTION FOR ASBESTOS CONTAINING MATERIALS IN PUBLIC SCHOOLS. I Have Read The Above Statement
Responsible Electronic Use Guidelines for Students

I have access to the Internet, school networks and electronic devices so I can…
expand my learning;
communicate with others about what I am learning;
research topics for class projects or for my personal learning;
create products highlighting my learning;
learn how to be a responsible and productive digital citizen.

Here are some things I need to know:
Electronic devices include but are not limited to computers, netbooks, iPads, iPods, tablets, cell phones, cameras, and other electronic devices that allow me to create and communicate.
I am responsible for all my online activities that take place through the network connection with my school’s devices or through access with my own personal electronic devices.

I am responsible for obeying all laws, including copyright. This also means I may not use the District logo or other District-owned content on my personal posts.

I do not have the right of privacy when accessing the Internet or network while at school.
Communicating electronically includes using my camera and cell phone to communicate visually.
When communicating electronically, I should ask myself: Is it safe? Is it kind? Is it respectful? Is it appropriate?

I do not have an absolute right to take, publish/post photographs or videos of others at school, as it may impact their individual rights of privacy.

Bullying or harassing someone either in person or electronically is wrong, violates the Code of Student Conduct, and is against the law.
Information I find on the Internet is not necessarily true or accurate.
There are filters to prevent access to inappropriate information, but no filter is perfect. I must protect myself by knowing how to close a window or click on the back button.

I can learn more about being a responsible digital citizen at http://www.safeflorida.net/safesurf.
Here’s what I agree to do as a responsible and productive digital citizen:

I will follow all school rules and laws when using electronic devices at school.

I will not damage equipment, upload harmful files, damage files, delete files, or access someone else’s files because it impacts others.

I will keep my password to myself and will not share it with others.

I will not search for or try to access obscene, harmful, or inappropriate material.

If I accidentally access inappropriate materials, I will close the window and tell a responsible adult.

I will not post or send hurtful, offensive or inappropriate material.

I will behave honestly, fairly, and with integrity when posting online, including my social networks.

I will follow rules of network etiquette, and I will be polite when communicating with others electronically. I will not use bad language or access messages from others who use bad language.

I will not post or share pictures of others without their knowledge and approval.

I will stay safe and will never meet or give out personal information such as my name, phone number, or address to someone I meet on the Internet without the express permission of my parents and/or teachers.

I will discuss my online activities with my parents so they understand how I am learning to be a good digital citizen.

My teachers and administrators have the right to access whatever I do online while in school if they are concerned about my safety or the safety of others.

I will not use others’ work without permission or without citing their work according to copyright laws.

If I’m not sure how to do something or whether something is okay to access or do, I will ask a responsible adult.

What happens if I violate this agreement and am not a responsible digital citizen?
Violations of this agreement will result in disciplinary action according to the Code of Student Conduct.

I have read The Terms and Conditions of the Responsible Electronic Use Guidelines for Students.

Responsible Electronic Use Guidelines for Students

I have access to the Internet, school networks and electronic devices so I can…
expand my learning;
communicate with others about what I am learning;
research topics for class projects or for my personal learning;
create products highlighting my learning;
learn how to be a responsible and productive digital citizen.

Here are some things I need to know:
Electronic devices include but are not limited to computers, netbooks, iPads, iPods, tablets, cell phones, cameras, and other electronic devices that allow me to create and communicate.
I am responsible for all my online activities that take place through the network connection with my school’s devices or through access with my own personal electronic devices.

I am responsible for obeying all laws, including copyright. This also means I may not use the District logo or other District-owned content on my personal posts.

I do not have the right of privacy when accessing the Internet or network while at school.
Communicating electronically includes using my camera and cell phone to communicate visually.
When communicating electronically, I should ask myself: Is it safe? Is it kind? Is it respectful? Is it appropriate?

I do not have an absolute right to take, publish/post photographs or videos of others at school, as it may impact their individual rights of privacy.

Bullying or harassing someone either in person or electronically is wrong, violates the Code of Student Conduct, and is against the law.
Information I find on the Internet is not necessarily true or accurate.
There are filters to prevent access to inappropriate information, but no filter is perfect. I must protect myself by knowing how to close a window or click on the back button.

I can learn more about being a responsible digital citizen at http://www.safeflorida.net/safesurf.
Here’s what I agree to do as a responsible and productive digital citizen:

I will follow all school rules and laws when using electronic devices at school.

I will not damage equipment, upload harmful files, damage files, delete files, or access someone else’s files because it impacts others.

I will keep my password to myself and will not share it with others.

I will not search for or try to access obscene, harmful, or inappropriate material.

If I accidentally access inappropriate materials, I will close the window and tell a responsible adult.

I will not post or send hurtful, offensive or inappropriate material.

I will behave honestly, fairly, and with integrity when posting online, including my social networks.

I will follow rules of network etiquette, and I will be polite when communicating with others electronically. I will not use bad language or access messages from others who use bad language.

I will not post or share pictures of others without their knowledge and approval.

I will stay safe and will never meet or give out personal information such as my name, phone number, or address to someone I meet on the Internet without the express permission of my parents and/or teachers.

I will discuss my online activities with my parents so they understand how I am learning to be a good digital citizen.

My teachers and administrators have the right to access whatever I do online while in school if they are concerned about my safety or the safety of others.

I will not use others’ work without permission or without citing their work according to copyright laws.

If I’m not sure how to do something or whether something is okay to access or do, I will ask a responsible adult.

What happens if I violate this agreement and am not a responsible digital citizen?
Violations of this agreement will result in disciplinary action according to the Code of Student Conduct.

I have read The Terms and Conditions of the Responsible Electronic Use Guidelines for Students. I confirm that I have read and agree to the Responsible Electronic Use Guidelines for Students
Disability Disclosure

Pasco County Schools (the District) hereby stipulates and affirms its policy of offering equal educational opportunities for all persons regardless of race, color, ethnicity, religion, national origin, age, gender, marital status, disability, genetic information or legally-protected characteristic. As such, it is the policy of the District to provide reasonable substitutions for any person enrolled in a postsecondary vocational programs who is hearing impaired, visually impaired, dyslexic or who has a specific learning disability where failure to meet the requirements is related to the disability. In order to receive disability accommodations or substitution, qualifying students must provide documentation that clearly shows evidence of a disability to the Special Populations Coordinator for individual consideration. The Special Populations Coordinator may be contacted at (727) 774-1731.

Confirm That You Have Read The Disability Disclosure

Disability Disclosure

Pasco County Schools (the District) hereby stipulates and affirms its policy of offering equal educational opportunities for all persons regardless of race, color, ethnicity, religion, national origin, age, gender, marital status, disability, genetic information or legally-protected characteristic. As such, it is the policy of the District to provide reasonable substitutions for any person enrolled in a postsecondary vocational programs who is hearing impaired, visually impaired, dyslexic or who has a specific learning disability where failure to meet the requirements is related to the disability. In order to receive disability accommodations or substitution, qualifying students must provide documentation that clearly shows evidence of a disability to the Special Populations Coordinator for individual consideration. The Special Populations Coordinator may be contacted at (727) 774-1731.

Confirm That You Have Read The Disability Disclosure I Have Read The Disability Disclosure
Terms and Conditions

I certify that the information on this application is correct to the best of my knowledge. By signing below I hereby agree to all the information provided and furhtermore give my permission for the use of this data included herin in managing the program for which I am registered.

Also, by submitting this application I understand that I am not guaranteed acceptance into a program.

Confirm that you have read and agree to the terms and conditions.

Terms and Conditions

I certify that the information on this application is correct to the best of my knowledge. By signing below I hereby agree to all the information provided and furhtermore give my permission for the use of this data included herin in managing the program for which I am registered.

Also, by submitting this application I understand that I am not guaranteed acceptance into a program.

Confirm that you have read and agree to the terms and conditions. I have been notified of and agree to the terms and conditions at Marchman Technical College